The chart below identifies updates to our Medical Necessity Guidelines. For additional details, refer to the Medical Necessity Guidelines page on our Point32Health provider website, where you can find coverage and prior authorization criteria for our Harvard Pilgrim and Tufts Health Plan lines of business.

Updates to Medical Necessity Guidelines (MNG)
MNG TitleProducts AffectedEffective DateSummary
Percutaneous Tibial Nerve StimulationHarvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether10/1/2026CPT code 64566 will no longer require prior authorization, and will continue to be covered for non-neurogenic urinary dysfunction including overactive bladder symptoms. Refer to the MNG for diagnosis codes considered medically necessary. 

Behavioral Health Inpatient and 24 Hour Level of Care Determinations

 

 

Behavioral Health Level of Care for Non-24 Hour/Intermediate/Diversionary Services

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options10/1/2026
  • Administrative criteria updates to improve reviewer workflow and ease of use. 
  • Added new American Society of Addiction Medicine (ASAM) 4th Edition adolescent and transition-aged youth levels of care across the continuum, including outpatient, intensive outpatient, medically focused outpatient, residential, and inpatient treatment settings.
  • Updated Adult Level 2.7 Medically Managed Intensive Outpatient Treatment.
Noncovered Investigational Services Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care9/1/2026Radiation oncology CPT codes 77437, 77438, and 77439 have been removed from the Noncovered Investigational Services list and are now covered without prior authorization. 
Evolent prior authorization programHarvard Pilgrim Commercial 9/1/2026

Prior authorization is now required for CPT code 93356 (Myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics [List separately in addition to codes for echocardiography imaging]) through our vendor program with Evolent. 

93356 is an add-on code and may be covered only when submitted on the same claim as CPT code 93307 or 93452 as the primary code approved by Evolent.